Annals of the Royal College of Suirgeons of England (I977) vol 59

Samuel Pepys and his stones

Sir Eric Richles MC MS FRCS Honorary Curator of Ilistorical Surgical Instruments, Royal College of Surgeons of England. Past Treasurer of Christ's Hospital Introduction enlightened lay opinion' was that the 'her- In the early hours of Wednesday 26th May editary' stone hitherto lodged in his kidneys 1703 Sainuel Pepys died at . His was carried into the bladder. Pepys himself death was reported to his friend attributed it to the weight of water he had by John Jackson, his nephew, who advised an drunk; it was attended by haematuria. He autopsy. This revealed a nest of seven stones recovered and on leaving Cambridge had in the left , irregular in shape, weigh- acquired a wide circle of friends, a taste for ing 42'oz; they were linked together and the beer, and a BA. He was offered employment kidney was entirely ulcerated and adherent. by his cousin, Sir Edward Montagu, and in I begin with his death rather than his birth I655, at the age of 22, he fell deeply in love to show that as well as functional symptoms and married Elizabeth de St Michel, a French he had organic calculous . Huguenot who was only I5. Recently Newman' aptly called the functional He soon began to have increasing symptoms symptonis 'the wind of colic'. They included of stone. In East Anglia stone in the bladder the oft-repeatedl distension and constipation of in children and ycoung people was common. mulcous colitis, all made worse by anxiety and They all had a similar diet and lived in the improved by relief after a successful operation, same environment; his mother, his brother, or on its anniversary, or by the magical and his aunt had stone. On 24th August i 66o properties of a hare's foot, especially if it 'he found his Mother was not very well and included a joint as advised by Benjamin Bat- gave her a pint of sack'. Notwithstanding this ten on 2oth January I665. Pepys was buried sensible treatment her pain became greater and in a vault of his own making near his wife greater and on 5th December she had just and his brother Thomas at St Olave's Church. nevly voided a stone which she had dropperA Samuel Pepys, the son of a tailor, was born into the fire; she found it again toi show to on 23rd February I633 at Salisbury Court near him. She recovered wvell and lived for six St Bride's Church in the City of . He years. His brother John also had the symptoms came from an East Anglian family from whom and 'makes bloody water with great pain, it the Pepys of Norfolk descended. He spent his beginning juist as mine did. I pray God help youth partly in North London at Kingsland him'. Hi_.Autnt Jane at Brampton 'voided a and partly in the country at Brampton in great stone, the first time that ever I heard . He went to she was trouibled therewith'. Grammar School and from i646 to I650 to St Paul's Sch(ool, wvhere he received a classical Aetiology and site eduication and won a Spendluffe Scholarship at In the case of Pepys himself his first stone Magdalene College, Cambridge. was formed in the left kidney. There vwas, In I653, when he was 2o and still at Cam- however, a high incidence of primary vesical bridge, he had the first symptoms of stone in calculus in children wvhich inpired the Norwich the urinary tract. After a long walk to Barn- school of lithotomv described bv Batty Shaw'. well Abbey on a hot summer day he and his was endemic in Norfolk and in friends slaked their thirst at Aristotle's Well the surrounding countrvside. Suggested With great draughts of cold vater. On return causes wNere the cold north-east vinds, the he was seized writh the violent pain of renal chialk subsoil with resultant hard water, and colic and lay for sorme days in agony7; the the inadequiate supply of milk contrasted vith Paper read to the Section of the Ilistory of Medicine of the Royal Society of Medicine on 3rd March T976. Published by lpemission of the Fditor of the Proceedings of the Royal Society of Medcine. 12 Sir Eric Riches the abundant amount of beer, made from Composition native barley. The standard of living of the Primary stones from the bladder were lamin- farm workers was low; the average diet was ated, the layers varying with the reaction of deficient in cheese, meat, protein, and vege- the . Two are illustrated. One from the tables and contained too much cereal. William Middlesex Hospital Museum (Fig. i), removed England4 believed that a defective diet was by Mr Amott in I84I, came from a boy of the main cause, but by I949 Ridley Thomas5 I5 who had had symptoms for 9 years. An- found that primary bladder stones in youth other (Fig. 2), from a boy of I4, was removed had vanished between the years i 910 and by lateral lithotomy under general anaesthesia I930. This coincided with the change from by Mr Henry Mitchell in i8589; it was larger grain-producing to mixed farming. Andersen6 and adherent and slipped from the forceps at discounts a lack of vitamin A as a major cause the first attempt. Each has a nucleus of uric of stones and believes that primary bladder acid or ammonium urate with layers of calcium stones are caused by a diet consisting almost , , and calcium phosphate. exclusively of one cereal. He has shown per These are the endemic primary bladder stones contra that stones in the upper urinary tract of East Anglia in the 17th century. J G have increased concomitantly with a rise in Crosse'0, a Norfolk surgeon, reported that living standards7. 55% of bladder stones affected patients under Pepys lived well, certainly in comparison the age of 20. with the East Anglian farm labourers. Per- The picture has now changed; today bladder haps that is why his stones started in the kid- stone more often affects older patients and is ney; he had them already at the age of 20, associated with outflow obstruction or in- passed two, (after renal colic) when he was 32, fection or occasionally a foreign body or a para- and had them when he died at the age of 70. thyroid adenoma. One that descended to the bladder was re- moved when he was 25. It did not prevent Pepys's symptoms his taking a degree at Cambridge, working as Although Pepys did not start his until a clerk in the Exchequer, and getting married. he was 27 (ist January i66o), nearly two years after he had been cut for the stone, he left a Primary stones in the kidney, especially record, written in I677 when he was 4511, of when fixed, are more likely to remain 'silent' the symptoms which made an operation essen- than those in the bladder, but they cause pain in the back, Pepys's frequent complaint. Either can cause haematuria; a bladder stone more often causes pain on micturition or movement. Pepys evidently had symptoms from both sources-chronic back pain from fixed renal stones and acute renal colic if a stone descended the ureter- as well -as the functional symptoms already mentioned. XTesical calculi coexisting with upper tract calculi are surprisingly rare. Swift Joly' found that out of I 97 patients with stone in the upper urinary tract, only 6 (3.04%/O) had stones in the bladder as well. In a similar series of 564 patients with stones in the upper tract I have found only 29 (5.14%) with stones also in the bladder. It seems probable that Pepys would fall into FIG. I Vesical calculus from a boy of 15 re- this small category of those who have both moved by perineal lithotomy by Mr J M renal and vesical stones; it was quite usual for Arnott in I84I. About the size of the ball used him to be unusual. in real tennis as played by Charles II. Samuel Pepys and his stones 13 a knife and a hook. The greater or Marian operation (1522) was used for Pepys. I will give the details but must first say that it was improved by Pierre Franco, who incised the bladder neck instead of tearing it as advised by Pare"4 and often made it a two-stage procedure. This operation remained in vogue until nearly the end of the I7th century. Many of the self-taught itiner- ant lithotomists used it". Lateral lithotomy replaced the Marian operation. Frere Jacques learnt the technique from Pauloni. After one successful operation he was allowed to operate in Paris. Crowds of up to 200 came to watch him; tickets were issued and guards posted. His mortality was

...... high (40%) so he had to leave Paris and ...... - - 1 learn some anatomy. It was left to Cheselden FIG. 2 Vesical calculus from a boy of I4 re- of St Thomas's in I7I8 to perfect it; he was moved by lateral lithotomy by Mr Henry born too late to, operate on Pepys, whose Mitchell in I858. About the size of a modern lithotomy preceded Cheselden's appointment lawn tennis ball. by 6o years. tial. He wrote, 'I remember not my life with- Suprapubic lithotomy This, 'the high out the pain of the stone in the kidneys (even operation', was first performed 'faute de to the making of bloody water upon extra- mieux' by Pierre Franco in i 56 on a child ordinary motion)'. From the age of 20 the of two and used by John Douglas in 17 I9 and bladder stone gave a constant succession of by Cheselden in 172316. fits of pain till the age of 25. When the Perineal lithotomy has become a rare weather was very cold he had to pass urine operation. Cheselden was said always to turn painfully and frequently and the blood in it pale when about to cut for the stone and alarmed him. He knew that although the Charles Bell also blanched"7. operation was common, it was dangerous and painful, and he accepted the decision. He was only a small man but he had great courage Pepys's lithotomy and bravely faced the dangers and the pain of The lithotomist chosen for Pepys was Thomas lithotomy. In default of an anaesthetic a Hollyer, of St Thomas's, where he was 'surgeon sponge soaked in a complicated mixture of for scald heads' in I638. He married a niece opiates and mandragora was given to the of Edward Molins, lithotomist at St Bartholo- patient to inhale"2. Speed in operating was mew's, and succeeded him'8. His son, Thomas essential. junior, became lithotomist at Bart's as well as St Thomas's in association with James Molins. Lithotomists were jealous of their Operations in vogue in I658 privileo-es but still flourished as surgeons until I will tabulate those operations I described to i 86q'", 20 the Section of Urology of the Royal Society of Thomas Hollyer (I 6oq-70) was described Medicine 4I years ago". by John Ward (1647-73)21 as the great surgeon Perineal approach Various types of who had been a poor boy in Coventry, where perineal lithotomy preceded the suprapubic his father was a cobbler or at best a poor shoe- operation. maker. He was by all accounts a skilful stone The lesser operation of Celsus had been used cutter; he had been a pupil of Edward Molins for about i6 centuries. It was intended for and he called in James Molins as a consultant. children and required only two instruments, Hollyer had cut 40 patients in one year and all 14 Sir Eric Riches placed on the table with his buttocks raised, his legs flexed, and the hands bound to the knees. Immobilization of the limbs was further ensured by four strong men. A typical set of lithotomy instruments is shown in Figure 3. A curved probe or bougie with a slit on its left side was thrust through the and into the bladder23. The scrotum was lifted by an assistant to, leave the left side of the perineum exposed. A cut was made on to the slit in the probe, no larger than the thumb, avoiding the seam of the perineum and the anal orifice. The gorget was inserted into the opened urethra and the channel kept open with the pair of conductors or guiders. The staff was withdrawn. The voracious and vociferous crows-beak or duck- bill forceps were passed into the bladder to search for the stone. If the opening was too small Pare's dilator was inserted and opened until the forceps with the stone could be with- drawn21. It was examined for cracks or facets; any blood clot or fragments were removed and no pieces left behind. Other forceps were available-for example, Pare's and Aston Keys'. A very large stone could be crushed by heavy forceps (Brodie type) and removed piecemeal. Pepys's operation was a success. The stone, as big as a tennis ball25, was complete and FIG. 3 Instrutments used in the operation by intact. The wound healed but reopened 40 the Apparatus Major. From above: grooved years later, three years before his death. Pepys staff, lithotome, gorget, conductors, crow's- had a case made for the stone so, that he could beak forceps, duck-bill forceps, Pare's dilator show it to encourage others similarly afflicted; (aperiens), button, scoop. (Reprinted from the it cost him 24 shillings. Annals of the Royal College of Surgeons21.) The personal experience of another patient has also been described2". He was an intelligent recovered, but the next four all died. One man who had many of the same symptoms as had a ragged stone, difficult and dangerous to Pepys; they began in i8oi when he was 23 remove; for the rest it has been assumed that and became worse in stages, including one his instruments, which were never sterilized22, of constipation and flatulence. By I 8 i i he had become septic. had pain, difficulty, chordee, and haematuria The operation took place on 26th March and finally could pass urine only on his knees I658 at Salisbury Court, the home of Pepys's with his head on the bed. A doctor attempted cousin Jane Turner; only wealthy patients to sound him but failed; the patient the;n could afford to go into hospital. Dr Molins seized the bougie and passed it himself, hit- prescribed elaborate preoperative medication ting the stone. Cline did the Marian operation containing mandragora which appears to have for him in 1812 with no general anaesthetic. been effective. Pepys's relations and friends He did not wince at the incision; the bougie were present, as was the custom. Preparation gave him his first real pain and it was relieved a few days earlier was by purging, bleeding, when the bladder was opened; the forceps and fomentation to the perineum. He was caused considerable pain. He heard Cline say, Samuel Pepys and his stones I5

'I have got it', and withdrawal produced It would seem likely that during this period indescribable pain because the bladder em- of recurrent pain a stone was passing down braced the stone firmly. He found the opera- the left ureter but getting arrested from time tion less painful than some of his previous to time. His lumbar pain was persistent and symptoms. Eighteen months later, after left he was very worried, as was his father27. His renal pain, he passed a small stone on three new general practitioner, Dr Burnett, said he occasions. had an ulcer in the kidney. i665 was an eventful year. In January the Recovery orchitis recurred and the severe pain in the was to recover from such an Pepys lucky left testicle ran up presently into the left operation with no complications. He was so with the result that he kept its kidney and kept aching all night. On the satisfied next day, 7th March, the pain became so anniversary on 26th March as a regular go home at noon. In two years he was at sea severe that he had to festival. In less than bed it began to abate. Anon he rose to pass and 'was in as good health as ever in his with no pain. on the water and out came two stones, life'. This was his invariable report Later he passed water again very freely and anniversary, but details of his functional com- plentifully. are not lacking. plaints in between times This was the ultimate stage of the left Four years after the operation (26th March ureteric colic; the ureter was unblocked, the I662), being again by God's mercy in very stones entered the bladder, and were small good health, he gave a dinner party followed from enough to be passed. by a musical afternoon. To save his guests for I665 was excellent. a the His annual report the chores he had man-cook to dress Despite the hard winter he never had a fit of dinner and Jane to help with the washing up. He again gave the credit to the hare's In October i66i he had an attack of acute colic. left epididymo-orchitis which kept him off foot; he had now bought a hare in order to The old returned if get the whole foot with the joint in it, which work for four days. pain was would be more effective. he sat too long bare-legged to pare his corns. he told It continued intermittently throughout I662 He still thought that the severe ureteric colic and I663. Hollyer agreed that it was due to was due to the 'bruise' of the testicle and had constipation and assured him that it was no association with the passage of the two nothing to do with the stone. Pepys spent smal stones. several days in bed but was able to go to a He began to take a new interest in life and very fine lecture at Barber-Surgeons Hall on in his lady friends. He still had wind, which the kidneys, ureters, etc. and to see the speci- was worse if he ate alone, when he ate too mens on which it was based. His thirst for much and too quickly. On a cold morning he knowledge was insatiable. At home he could drank a cup of good drink which, he said, play a little music, read, teach his wife 'I am fain to allow myself during this plague 'arithmetique', and eat a very good meal 'as time, my physician being dead and surgeon much as he used to do'. Hollyer's enema of a out of the way whose advice I am obliged to pint of strong ale, 4 oz of sugar, and 2 oz of take'. He commented now that overfasting butter produced excellent results. He told him had filled him with wind, mightily, and nothing that all the slime in his urine was a good sign else had done it. and showed there was no fear of the stone. The main event of i666 was the Fire of Pepys ended I 663 on a subdued note and I 664 London. It extended from Pudding Lane to continued on the same lines. Pye Corner, fortunately stopping short of In May an attack produced most extra- Seething Lane. Pepys was anxious and busy ordinary anguish, crying, and roaring, but on but free from urinary symptoms. getting by chance on his knees in bed it The eleventh surgical anniversary was the stopped within an hour and he slept well. last one recorded in the Diary; his sight was Hollyer now thought that the stone had re- failing. He continued his self-imposed work curred and brought something to try and dis- for the Royal Mathematical School of Christ's solve it. Hospital and produced a 'short reflection' of i6 Sir Eric Riches

62 pages. I2 Garrison, F H (I921) Introduction to the History My time is up. I too must forbear and be of Medicine, 3rd ed. Philadelphia and London, contented to set down no more than is fit for Saunders. you and all the world to know. I cannot re- I3 Riches, E W (I935) British Journal of Urology, frain from giving you a final message of good 7, I40. 14 Keynes, G (ed.) (I95i) Ambroise Pari's Apologie will, which I am sure would have been and Treatise, p I89. London, Falcon Educational mightily approved of by Samuel Pepys. Books. I5 Desnos, E (I9I4) Encyclope'die fran aise d'Urologie, vol. i, p i. References i6 Cheselden, W (1723) A Treatise on the High I Newman, C E (1976) Records of the Osler Club, Operation for the Stone. London. 26th February. 17 Miles, A (I9I8) The Edinburgh School of Surgery 2 Bryant, A (I933) Samuel Pepys, The Man in the before Lister. London, Black. Making, London, Cambridge University Press. i8 Moore, N (I9I8) The History of St Bartholo- 3 Shaw, A B (1970) Medical History, I4, 22I. new's Hospital, vol. 2. London, Pearson. 4 England, W (I830) Observations on the Func- I9 Parsons, F C (I934) History of St Thomas's tional Disorders of the Kidneys. London and Hospital, vol. 2, p 30. London, Methuen. Norwich. 20 McInnes, E M (i963) History of St Thomas's 5 Thomas, J M R (I949) British Journal of Urology, Hospital. London, Allen and Unwin. 2I, 20. 2I Ward, J (I647-I673) Diary, transcribed by the 6 Andersen, D A (I962) British Journal of of Urology, 34, i6o. Medical Society London, vol. I, pp I-280; 7 Andersen, D A (I968) In Renal Stone Research vol. 2, p 5o6. Symposium, p 7. London, Churchill. 22 Power, d'A (I 930-3 i) British Journal of 8 Joly, J S (1929) In Stone and Calculous Disease of Surgery, i8, i, i85, 353, 541. the Urinary Organs, p 429. London, Heinemann. 23 Riches, E WV (I968) Annals of the Royal College 9 Mitchell, H (i 858) Transactions of the Patho- of Surgeons of England, 43, I85. logical Society, 9, 342. 24 Tolet, F (I708) Traite' de la Lithotomie. Paris. io Crosse, J G (I846) Report of the Fourteenth 25 Evelyn, J (I952) Diary, vol. 2, p 42, ioth June Anniversary Meeting of the Provincial Medical I669. London, Dent. and Surgical Association held at Norwich. 26 Marcet, A (I8I9) Medical and Chirurgical Trans- Worcester. actions, io, I, 147. ii Bryant, A (I935) Samuel Pepys, The Years of 27 Heathe, H T (I955) The Letters of Samuel Peril. Appendix, p 3"I. London, Cambridge Pepys and his Family Circle, letters 7 and I64. University Press. Oxford, Clarendon Press.